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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT L 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED y .(Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein deschbed.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage.or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address __-' / X �t5f City C4 Lot Size U a PM ,I , I Owner's Name tit-!' \ Dl V►�-P$. -Address I d�I S2 oC*l e)c., Phone Contractor 1"1��0 . Address � h �� r � - { a"V�� !��? = License No.q3k 3 f7 Phone "2 TYPE OF,WELL'°/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 1 DESTRUCTION ❑ PUMP INSTALLATION-9----- SYSTEM REPAIR ❑ OTHER-.0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE F FOUNDATION L•t"-.AGRICULTURE WELL OTHER WELL 14 -=-PITS/SUMPS �1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPE6IFICATlONS —0.Industrial ❑ Open Bottom--a-—0 Manteca Dia. of Well Excavation I Dla. of Well Casing ❑ Do estic"Wrivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications \i ❑ Public r } ❑ Other 1-1 Delta Depth of Grouf Seal Type of Grout ❑ Irrigation Depth_© Eastern_ Surface Seal Installed by fi Repair Pork;Done, ❑ Type ofPump H.P. State Work Done (� 1 M Well Destruction Elme Well Diaeterv, � Sealing Material (top 50'I Depth °}' Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is � � available within 200 feet.) Installation will serve:: ResidenceCommercial Other 4 Number of living'uriitsi�`�''Nurnber``of b'edrofoms�� + Character of soil to a depth of e3 feet:r# } 4. ` Water table depth ~ i SEPTIC TANK ❑. Type/Mfg's^ �,.. Ca�adcity No. Compartments � PKG TREATMENT PLT. ❑- � h rR*�vF Method of Disposal CA T pndation Distance to nearest: Well FouProperty Line O LEACHING LINE INo-& Length of lines — "\foia1 length/size (� I �0� 'a-- FILTER BED ❑ (,Distance to nearest: Well.��n Foundation Property Line ad SEEPAGE PITS-- —E] -Depth-12L N Number r ? 1k . SUMPS s< Distance to nearest: Well 5D Foundation P� Property Line �a DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and..that the work will be„done'in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District.' Home owner or licensed agent's signature certifies the follow ng: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become-subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performancesof,the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." `� The applicant must call for all required inspections. Complete drawing on reverse side. Signed X_�4A,,� Z- LA&�, Title: Date: '�7"dQ FO EPART T USE ONLY Application Accepted by Date �� ' Aree Pit or Grout Inspection by Date Final Inspection by ;t-- �d a-r�/Y Date--?,, Additional Comments: e7 �— ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t INFO FEE MOUNT DUE AMOUN/T�REMITTED CASH RECEIVED 9Y DATEy�}�7 PERCMIT MO. + + EH 13-24 1 REV.I/a 51 e �� „� 1�V p- U ✓ - EH 11-28 YYY 'r t